PPH Flashcards
Blood changes in preg physiologic
40% increase plasma volume
25% increased red cell mass
Def of PPH
Not much agreed upon:
- 500 in SVD, 1000 in C/S
- 10% reduction in Hct
How much of blood volume loss before hypotension, dizziness, pallor, oliguria occur?
10%
Main sx of genital tract hematomas
pelvic/rectal pressure/pain
Primary vs Secondary PPH
Primary w/in 24 hrs s/p delivery
Secondary 24hrs to 12 wks pp
Causes of Primary PPH
Uterine atony
Retained products (accreta)
Defects in coagulation
Uterine inversion
Causes of Secondary PPH
Subinvolution
Retained Products
Infection
Inherited coag defects
Red tube test
5mL of pts blood into tube, should clot in 8-10 min if fibrinogen is normal…if fibrinogen is low (
What conditions can cause clotting abnormalities?
HELLP prolonged fetal demise sepsis AFE placental abruptions significant hemorrhage (consumes clotting factors)
Risk factors for PPH
- Prolonged labor
- Rapid labor
- Augmented labor
- H/o PPH
- Distended uterus (twins, macrosomia, hydramnios)
- Operative delivery
- Episitomy esp Mediolateral
- Asian/hispanic
- Chorio
- PreE
Large bore iv
16 gauge
Uterotonics/doses
- methergine 0.2mg IM (maybe IU) q2-4 hrs; max 5 doses?
- hemabate (PGF2a) 0.25mg IM (IU?) q15-90 min, max 8 doses
- Cytotec (misoprostol/PGE1): 800-1000mcg/rectum (sublingual 10, 100mcg tabs or 5 200mcg tabs)
- Pitocin 10-40 units in 1L NS or LR continuous rapid infusion or 10 units IM
- Dinoprostone (PGE2) 20mg per rectum/vagina q 2 hrs
Uterotonic contraindication or side effects
- methergine (HTN)
- hemabate (asthma; relative CI renal, cardiac, hepatic disease; can cause diarrhea, fever, tachy)
- cytotec: can cause fever
- dinoprostone: avoid with HYPOtension, fever common; stored frozen, must be thawed to room temp
- pit: avoid undiluted rapid iv infusion –> hypotension
B-Lynch suture?
1-#2 catgut on large mayo needle, something that absorbs quickly so bowel does not get caught when uterus involutes
Oleary stitch
#0 polygycolic acid suture (vicryl), large blunt needle (5 Mayo)--into lower uterine segment as close to cervix as possible laterally come out around uterine artery or uetero ovarian artery branches through the broad ligament--good if uterine artery has been ligated...will not stop bleeding for uterine atony/accreta...may decrease blood loss while other interventions attempted. Identify the ureter!!
What if Oleary stitch does not slow bleeding?
Similar stitch across utero-ovarian arcade right by cornua
Uterine packing/tamponade techniques
- foley bulb: fill 60-80cc NS, 1 or more bulbs
- Blakemore-Sengstaken tube
- Bakri: 300-500ml NS
- uterine tamponade
- packing: cornu to cornu, 4 inch gauze (soak 5K units of thrombin in 5 mL sterile saline
When would you consider packing/tamponade?
when uterotonics fail to cause sustained uterine ctxns and satisfactory control of hemorrhage after vaginal delivery, temporizing, but if prompt response not seen, preparations should be made for XLAP
Hypogastric artery ligation successful?
Now found to be less successful than previously thought difficult, more for ppl with experience in this technique
Risk factors for placenta accreta
- over 35yo
- asherman’s
- previous uterine surgery: c/s; myomectomy
- submucous fibroids
How do you do a hypogastric artery ligation?
- open anterior leaf of broad ligament and lyse areolar tissue of the retroperitoneum
- identify external iliac, follow up to common
- now find internal iliac (about 4cm before splits into ant/post), identify anterior/posterior branches
- You try to ligate the anterior branch…but a lot of the time you will just ligate the whole internal iliac
- use permanent suture (polypropylene) or #1 silk go from lateral to medial, tie artery securely
What are some major complications of internal iliac artery ligation?
- you can ligate the external iliac –> ipsilateral leg (check dorsalis pedis/posterior tibial pulse!)
- accidentally lacerate internal iliac vein (just behind and medial to internal iliac artery) or external iliac artery (lateral) = exangunation
Heparin works on what pathway
Warfarin works on which pathway
PT/PTT? pathways?
Factors that start off each pathway?
PET=Extrinsic –> Warfarin –> VII
PITT = Intrinsic –> Heparin –> XII
Packed RBC Volume, increase hgb/hct?
240mL
3% hct, 1g/dL Hgb
Platelets volume, increase plts?
50mL
5-10,000 increase
FFP, volume, factors it contains, raise in Fibrinogen
250mL
Fibrinogen, Factor VIII and V, antithrombin III
10 mg/dL raise
Cryoprecipitate, volume, factors, raises what?
40mL
Fibrinogen, Factor VIII and XIII, von Willebrand factor
10mg/dL raise FIBRINOGEN
Risk of prior c/s with accretas
- 2% s/p 1st c/s
- 3% 2nd
- 6% 3rd
- ————— - 1 % 4th
- 3% 5th
- 7% 6th
Risk of accreta with Previa present and prior c/s
1st 3% 2nd 11% 3rd 40 % 4th 61% 5th 67%
When can you call IR for arterial embolization?
stable vitals, persistent bleeding (and if it is not excessive)
Can be used to preserver fertility
In what situation is autologous transfusion considered?
Person with rare antibodies
Risk factors for uterine rupture
small uterine horn operative delivery placenta accreta abnormal labor prior c/s
Should you repair uterine rupture?
If possible to preserve fertility
Inverted uterus management
Try to push it back up: holding a tennis ball, palm to fundus
May need to relax uterus: mag, terb, halogenated anesthetics, nitroglycerin
What happens if cannot manually revert uterus?
Rare situation
OR for exploration: Huntington’s: use babcocks/allis clamps on fundus and pull up
Haultain: cervical ring incision posteriorly, then digital repositioning of inverted corpus
